Pneumonia

1. incidence
   1. peaks in infancy & old age
   2. relatively high in childhood
2. resource-poor countries
   1. a major cause of childhood mortality
3. in > 50% of cases no causative pathogen IDed
4. younger kids
   1. viruses= most common cause
5. older children
   1. bacteria = commonest cause

1. vary with age
   1. newborn
      1. organisms from mum's genital tract
         1. esp group B strep
         2. G-ve enterococci
   2. infants & young kids
      1. respiratory viruses
         1. esp RSV
         2. commonest
      2. bacterial
         1. Strep pneumoniae
         2. Haem. influenzae
         3. Bordetella pertussis
         4. Chlamydia trachomatis
         5. Staph. aures
            1. infrequent but serious cause
   3. children > 5 yrs old
      1. Mycoplasma pneumoniae
      2. Strep pneumoniae
      3. Chlamydia pneumoniae
   4. all ages
      1. Mycobacterium tuberculosis

1. Prevenar
   1. conjugate vaccine
   2. immunogenicity vs 13 commonest serotypes of Strep pneumoniae
2. Hib (Haemophilus type B) vaccine

Annotations:

• consider pneumonia in children with neck stiffness or acute abdo pain

1. URTI followed by
   1. fever

      Annotations:

      • fever & difficulty breathing are the commonest presenting sx
   2. difficulty breathing
2. cough
3. poor feeding
4. of pleural irritation
   1. localised chest pain
   2. localised abdo pain
   3. localised neck pain
   4. all suggestive of bacterial infection
5. on examination
   1. tachypnoea
      1. best sign of pneumonia in kids

         Annotations:

         • don't forget to measure resp rate in a febrile child (so that you don't miss silent pneumonia).
   2. nasal flaring
   3. chest indrawing
   4. end inspiratory coarse crackles

      Annotations:

      • often don't hear dullness of percussion, decreased breath sounds or bronchial breathing (signs of consolidation) in young children
      1. over affected area
   5. reduced O2 sats
      1. indication for hopsital admission

1. CXR
   1. can confirm classic lobar pneumonia
      1. characteristic of Strep pneumo
   2. can't differentiate btw viral & bacterial pneumonia
   3. blunting of costophrenic angle
      1. due to assoc pleural effusion
         1. empyema & fibrin strands can form from these
            1. -> septations
               1. make drainage difficult
2. ultrasound of chest
   1. tell btw parapneumonic effusion & empyema

1. home
   1. most cases can be managed here
2. British Thoracic Society guidelines
3. indications for admission
   1. O2 sats <93%
   2. severe tachypnoea
   3. difficulty breathing
   4. grunting
   5. apnoea
   6. not feeding
   7. family unable to provide approp care
4. Abx
   1. choice determined by
      1. age
      2. severity of illness
      3. appearance on CXR
   2. newborns
      1. msot need broadspectrum
   3. older infants
      1. amoxicillin for most
      2. co-amoxiclav
         1. for complicated or unresponsive pts
   4. > 5 yrs old
      1. amoxicillin
      2. macrolide
         1. e.g. erythromycin
5. parapneumonic effusions
   1. resolve with approp Abx
   2. empyema developing from this needs drainage
      1. insert chest drain
         1. +/- fibrinolytic agent
            1. into intercostal space
            2. e.g. urokinase
               1. break down septations
      2. surgical decortication

1. simple consolidation on CXR & recover clinically
   1. follow up not needed
2. evidence of lobar collapse, atelactasis or empyema
   1. repeat CXR after 4-6 weeks
3. virtually all kids, even those w/ empyema recover fully